Centenarian abroad application form 2012

CENTENARIAN BOUNTY APPLICATION FORM The Centenarian Bounty is the award made by the President of Ireland to: (i) People living in Ireland who have reached 100 years (ii) Irish citizens born on the island of Ireland who have reached 100 years and who are living outside of the State.

People in category (ii) or their representatives should complete this application form.

PLEASE PRINT CLEARLY IN BLOCK CAPITALS. The following supporting documentation is required to confirm the age, identity, place of birth and Irish citizenship of the applicant: -

Applicant’s civil birth certificate and/or Irish passport; In cases where an applicant’s surname is different from their surname at birth, please provide a copy of the marriage certificate or other relevant documents; Two recent proofs of residency (such as official correspondence addressed to applicant regarding pension, utility bills, nursing home paperwork, etc.) The residency documentation must have been issued within the last 3 months.

All documentation must be original, photocopies will not be accepted.

The Bounty is issued by way of a cheque in local currency made payable to the applicant.

Therefore in advance of any Bounty being awarded, all applicants must confirm that they have a financial account in their own name to which the bounty payment can be lodged.

Officials of the Department of Foreign Affairs and Trade may seek additional material in order to confirm an applicant’s details and will be happy to discuss with applicants, or their representatives, the type of material that will meet the requirement for supporting documentation.

Completed form and supporting documents should be sent to: NEAREST IRISH EMBASSY/CONSULATE GENERAL (Details available at www.dfa.ie) or Centenarian Bounty Department of Foreign Affairs and Trade 80 St Stephen’s Green Dublin 2 Ireland Tel: (+353 1) 4780822 Fax: (+353 1) 4082026

CENTENARIAN BOUNTY APPLICATION FORM (FOR APPLICANTS RESIDENT OUTSIDE THE STATE)

1. APPLICANT’S DETAILS Name ______________________________________________________________________ Name at Birth (if different from above) ______________________________________________ Date of Birth _____________/______________/___________ (day)

(month)

(year)

Place of Birth ____________________________ (town)

____________________________ (county)

Current Residential Address __________________________________________________________________ (please include postcode/zip code if applicable) ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

Country of Residence __________________________________________________________ Telephone No. ________________________________________________________________ (please include international dial codes)

Please confirm, by ticking the box, that Financial Arrangements are in place for the lodgement of the Bounty.

(The Bounty is issued as a third party cheque, in the name of the applicant only and therefore must be lodged into an applicant’s financial account) Please indicate whether the Bounty should be sent directly to the Applicant’s Current Residential Address or to that of the Representative___________________________________

2. DETAILS OF THE APPLICANT’S REPRESENTATIVE (if the application is being completed by a relative or friend)

Name _______________________________________________________________________ Please describe the nature of relationship with claimant _____________________________ (e.g. family member, friend, nursing home manager, etc.)

Address _____________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________

Telephone No. ___________________________________________________ E-mail address (if available) __________________________________________

CENTENARIAN BOUNTY APPLICATION FORM (FOR APPLICANTS RESIDENT OUTSIDE THE STATE)

3. DECLARATION BY APPLICANT/REPRESENTATIVE I, _____________________________________, am an Irish citizen born on the island of Ireland (print name of applicant)

and I hereby apply for the Centenarian Bounty. I confirm that the details that I have provided in this application are true and correct.

Signature of Applicant _____________________________________ Date ____________________ If the above declaration is not signed by the Applicant, please explain why _______________________________________________________________________________ and the representative should complete the section directly below.

I, _____________________________________________________, submit this application on behalf (print name of representative)

of the applicant, ______________________________________________________________ (print name of applicant)

who is an Irish citizen born on the island of Ireland. I confirm that the details that I have provided in this application are true and correct.

Signature of Representative ________________________________Date ________________

4. SUPPORTING DECLARATION Note to Witness: Do not sign unless satisfied as to the identity of the applicant, not the representative.

You may be contacted to confirm the validity of your signature. This section should be completed by a member of one of the following professions, who is not a relative and currently practising in their field: Doctor, Religious, Manager of Irish Centre/Community Care organisation, Irish Diplomatic or Consular Officer I declare that the Applicant ________________________________________________________ (print name of applicant)

is known to me and is currently living at the address given in Section 1 of this application form.

The Declaration above (Section 3) has been signed in my presence.

Name _________________________________

Signature ________________________________

Occupation _____________________________ Contact Tel. No. __________________________ Witness Official Stamp

Date of Witnessing Application _________________________________

Please return this application form completed, together with the required documentation which confirms the age, identity, place of birth, current residency and Irish citizenship of the claimant. It should be noted that photocopies cannot be accepted.

Check list □ Civil Birth Certificate □ Marriage Certificate (if applicable) □ Two proofs of residency (utility bills, pension letters, etc.)